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Introduction to Finnish NCD Prevention
PREVENTION OF NONCOMMUNICABLE DISEASES SEMINAR, Helsinki 14.3.2011
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Global Health Burden
Estimated global deaths by cause, all ages, 2005
H IV/ A ID S
T uberculo sis
M alaria
C ardio vascular
diseases
C ancer
C hro nic respirato ry
diseases
D iabetes
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
18000000
20000000
Source : WHO 2005: «Preventing Chronic Diseases: A Vital Investment»
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Global Public Health in Transition
Chronic diseases – especially cardio-vascular diseases
Leading health problem in industrialized countries
Main killers and rapidly growing problem in developing countries
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Lifestyle Transition
Emerging global epidemic of NCDs is to a great extent a consequence of changes in the diets, of declining physical activity and of increase of tobacco use
The determinants of these changes are urbanisation, changes in occupations, population ageing and many global influences
Risks are increasingly accumulating in lower socio-economic groups of the population
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3
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North Karelia ProjectPrinciples for Defining the Intermediate Objectives
• Due to the chronic nature of CVD, the potential for the control of the problemlies in primary prevention
• The risk factors were chosen on the basis ofbest available knowledge: - previous studies- collective international recommendations- epidemiological situation in North Karelia
• Chosen risk factors:- smoking- elevated serum cholesterol (diet)- elevated blood pressure
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Main Principles of the North Karelia Project
• Prevention is the only sustainable public health approach
• Risk factors identified by prospective studies, closely linked with certain behaviours - deeply enrooted in the community
• Community based preventive programme
1 Target: the community (not individuals)
2 Intervention: through community structures (not external intervention)
• Emphasis on community organization, general community changes
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From Karelia to National Action
• First province of North Karelia as a pilot
(5 years), then national action (1972–77)
• Continuation is North Karelia as national demonstration (1977–95)
• Good scientific evaluation to learn of the experience
• Comprehensive national action
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Evaluation/Monitoring
- North Karelia – all Finland
- Monitoring systems
• health behaviour
• risk factors
• nutrition
• diseases, mortality
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Intervention Principles
• Restricted risk factor targets, based on epidemiological knowledge
• Sound behavioural & social science principles for planning, implementation and evaluation
• Intervention flexible to respond to the naturally occurring opportunities and feedback (monitoring)
• Key principles: Community organization (working with the community to change physical and social environment conducive to target behavioural changes) = To make the healthy lifestyles the easy ones.
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Use of Butter on Bread (men age 30–59)
0
10
20
30
40
50
60
70
80
90
100
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province
Kg/m2
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Butter consumption per capita in Finland
0
2
4
6
8
10
12
14
16
18
20
1955 1965 1975 1985 1995 2005
Co
nsu
mp
tio
n (
kg
per
cap
ita)
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Milk Consumption in Finland in 1970 and 2006 (kg per capita)
0
20
40
60
80
100
120
140
kg
1960 1970 1980 1990 2000 2010
Whole milk
Whole form milk
Low fat milk
Skim milk
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Use of Vegetable Oil for Cooking (men age 30–59)
0
10
20
30
40
50
60
70
1972 1977 1982 1987 1992 1997 2002 2007
North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province
%
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Fruits and Vegetables – Supermarkets
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Salt Intake in Finland 1977–2002
0
2
4
6
8
10
12
14
16
1977
1979
1981
1982
1987
1991
1992
1994
1997
1998
2002
Per capita
statistics
Dietary surveys,
men
Dietary surveys,
women
Sodium excretion,
men
Sodium excretion,
women
Lin. (Sodium
excretion, men)
Lin. (Per capita
statistics)
g/d
ay
Year
Sources: Karvonen et al. 1977, Nissinen et al. 1982, Pietinen et al. 1981, Pietinen et al. 1990, Valsta 1992,
KTL/Nutrition Report 1995, KTL/ FINDIET 1997 and FINDIET2002 Studies, KTL/unpublished information
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18
Fat intake in Finland 1982-2007
EN%
Year
Recommendations
0
10
20
30
40
1982 1987 1992 1997 2002 2007
Total fat (~ 30 EN%)
SFA (~10 EN%)
MUFA (10-15 EN%)
PUFA (5-10 EN%)
Sources:Uusitalo et al. 1986
Kleemola et al. 1994
Findiet Study Group 1998
Männistö et al. 2003
Paturi et al. 2008
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Serum Cholesterol in Men Aged30–59 Years
FINRISK Studies 1997 & 2002
mmol/l
5
5,5
6
6,5
7
7,5
1972 1977 1982 1987 1992 1997 2002 2007
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu
Lapland
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Systolic Blood Pressure in Men Aged 30–59 Years
120
130
140
150
160
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province
mmHg
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Smoking in men (30–59 y)
0
10
20
30
40
50
60
1972 1977 1982 1987 1992 1997 2002 2007
North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province
North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007
%
Pekka Puska, Director General
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Age-adjusted mortality rates of coronary
heart disease in North Karelia
and the whole of
Finland among
males aged
35–64 years
from 1969
to 2006.
Mortality per
100 000
populationAge-standadized to European population
start of the North Karelia Project
extension of the Project nationally
North Karelia
All Finland
- 85%
- 80%
22
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Observed and Predicted Declines in Coronary Mortality in Eastern Finland, Men
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
1972 1977 1982 1987 1992 1997 2002 2007Year
%
Observed
Predicted
Cholesterol
Blood pressure
Smoking
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Mortality Changes in Finland from 1969–71 to 2006 (Men 35–64 Years, Age Adjusted)
Rate (per 100.000) Change from
1969–71 2006 1969–71 to 2006
All causes 1328 583 - 56%
All cardiovascular 680 172 - 75%
Coronary heart disease 489 103 - 79%
All cancers 262 124 - 53%
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• A comprehensive, determined and theory-based community program can have a meaningful positive effect on riskfactors and life styles
• Such changes are associated with respective favourable changes in chronic disease ratesand health of the population
• A major national demonstration program can be a strong tool for favourable national development in chronic disease prevention and health promotion
CONCLUSIONS
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Why success in North Karelia
• Appropriate epidemiological and behavioural framework
• Restricted, well defined targets
• Good monitoring of immediate targets (behaviours, process)
• Flexible intervention
• Emphasis in changing environment and social norms
• Working closely with the community
• Positive feedback, work with media
• International collaboration, support from WHO
• Close interaction with national health policy, integration with National Public Health Institute
• Long term, dedicated leadership
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From Karelia to National Action
Major Elements of Finnish National Action 1.
• Research & international research collaboration
• Health services (especially primary health care)
• North Karelia Project, other demonstration programmes
• Health Promotion Programmes (coalitions,
NGO’s, collaboration with media etc.)
• Schools, educational institutions
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Major Elements of Finnish National Action 2.
• Industry, business – collaboration
• Policy decisions, intersectoral collaboration, legislation
• Monitoring system: health behaviours, risk factors, nutrition, diseases, mortality
• International collaboration
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WHO’S NCD STRATEGY 2000
NCD’s a priority
Prevention key
Integrated approach, targeting main behavioural factors: diet, physical activity and tobacco
WHO NCD ACTION PLAN (WHA 2008)
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Prevention targetsthe population levelsof most importantrisk factors.
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0 1000 2000 3000 4000 5000 6000 7000 8000
Occupational risk factors for injury
Unsafe health care injections
Vitamin A deficiency
Zinc deficiency
Urban air pollution
Iron deficiency
Indoor smoke from solid fuels
Unsafe water, sanitation, and hygiene
Alcohol
Physical inactivity
High Body Mass Index
Fruit and vegetable intake
Unsafe sex
Underweight
Cholesterol
Tobacco
Blood pressure
WORLDDEATHS IN 2000 ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS
Number of deaths (000s)
Source: WHR 2002
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SIX OF THE SEVEN TOP DETERMINANTS OF MORTALITY IN DEVELOPED COUNTRIES RELATE TO HOW WE EAT, DRINK AND MOVE
DIET AND PHYSICAL ACTIVITY, TOGETHER WITH TOBACCO AND ALCOHO, ARE KEY DETERMINANTS OF CONTEMPORARY PUBLIC HEALTH
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RISK FACTORS
─Tobacco: FCTC (2003)
─Diet & Physical activity: global strategy (2004)
─Alcohol: global strategy under preparation (2010)
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Sound Combination of Population Strategy With High Risk Strategy
1. Population strategy:
- Greatest public health gains
- Cost effective
- Results also in other health benefits
2. High risk strategy:
- Great benefits to the persons concerned
- Effective use of health services
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Theory and Action for Effective
Programmes and Policies
MEDICAL
KNOWLEDGE
SOCIAL & EFFECTIVE
BEHAVIORAL PROGRAMS
THEORY POLICIES
STRONG
SUSTAINED
IMPLEMENTATION
During the last few years a great number of strategies and plans for evidence – based, effective prevention and health promotion have been produced
Many important priorities have been identified.
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43
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IDENTIFYING IMPLEMENTING
PRIORITIES THEM
FROM PRIORITIES TO IMPLEMENTATION
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PUBLIC
POLICY
HEALTH PROGRAMME
POPULATIONPRIVATE
SECTOR
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CVDs are to a Great Extent Preventable Diseases
• Medical evidence for prevention exists.
• Population-based prevention is the most cost-
effective and the only affordable option for major
public health improvement in NCD rates.
• Major changes in population rates can take place
in a surprisingly short time.
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Finland Has Shown
• Prevention of major chronic diseases is possible and pays off
• Population based prevention is the only cost effective and sustainable public health approach to chronic disease control
• Prevention calls for simple changes in some lifestyles (individual, family, community, national and global level action)
• Influencing lifestyles is a key issue
• Many results of prevention occur surprisingly quickly
(CVD, diabetes) and also at relatively late age
• Comprehensive action, broad collaboration with dedicated leadership and strong government policy support
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THANK YOU